Equipment
Equipment for video-assisted thoracoscopic surgery (VATS) includes the following:
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5- or 10-mm video thoracoscope, with a 0º or 30º lens and a three-chip charge-coupled device video camera
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Sponge-holding forceps
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Long-blade diathermy pen
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Endoscopic biopsy forceps (for simple pleural biopsy)
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Endoscopic staple-transection devices (for lung wedge resection)
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Rigid or flexible trocar cannula and/or sterile plastic bag
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Thoracotomy tray
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Chest tube drainage device with water seal
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Suction source and tubing
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Sterile gloves
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Sterile drapes
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Gauze squares
Patient Preparation
Anesthesia
For most VATS procedures, general anesthesia with selective single-lung ventilation using a double-lumen endobronchial tube is preferred. Left-side intubation is usually performed unless a left pneumonectomy is anticipated. A single-lumen endotracheal tube with a bronchial blocker is an acceptable alternative.
For treatment of pleural effusions and sympathectomy, single-lung ventilation with low tidal volumes is a better option and allows adequate visualization of the pleural space. Moreover, CO2 can be insufflated to facilitate partial collapse of the lung.
For pediatric patients, a single-lumen tube is used with the tip placed into the contralateral mainstem bronchus.
Thoracoscopic evaluation of an awake, nonintubated, nonventilated patient in an ambulatory setting under monitored anesthesia care has been described. [11] Irons et al, in a study of 73 patients who underwent elective minor VATS, found nonintubated general anesthesia with spontaneous ventilation via a supraglottic airway device to be a feasible alternative to intubated general anesthesia. [12]
A study by Lee et al found that during nonintubated VATS, transcutaneous CO2 monitoring was more accurate in detecting hypercapnia than end-tidal CO2 monitoring. [13]
For major lung resections, typed and crossmatched blood should be available.
Two large-bore intravenous (IV) lines and an arterial line should be also placed.
Positioning
The patient is turned to a full lateral decubitus position, and the operating table is flexed to widen the rib spaces on the operation side. The positions of the surgeon and assistant depend on the site of the pathology as suggested by preoperative imaging. The surgeon stands facing the site of the pathology, with the camera-holding assistant on the same side. The television monitor is positioned so that the surgeon, the site of pathology, and the monitor are aligned to allow the surgeon to look straight ahead when operating.
Alternatively, the patient can be positioned supine with a roll under the back to bump him or her up and provide access to the pleural space from a more anterior approach.
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Video-assisted thoracoscopic surgery (VATS). Examination for evidence of metastasis.
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Video-assisted thoracoscopic surgery (VATS). Pleural adhesions on medical thoracoscopy.
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Video-assisted thoracoscopic surgery (VATS). Example of positioning of VATS instruments; three ports are used, with camera in center position of triangle.
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Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
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Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
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Video-assisted thoracoscopic surgery (VATS). Thoracoscopic wedge resection.
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Video-assisted thoracoscopic surgery (VATS). Pleural biopsy.
